PainZio Eligibility Form
This form will help us determine if we are the right fit to help you with your chronic pain issues.
Name
*
First Name
Last Name
Mobile/WhatsApp (10 digits)
*
We do not spam or share your number with other companies.
Format: 0000000000.
Email
*
Eg. name@gmail.com; We do not spam or share your number with other companies.
Are you 18 years or above as of the date of filling this form?
*
Yes
No
In which city do you live where you require the services?
*
Bangalore City
Outside Bangalore City/Rest of India
Other
Select all the option(s) that apply to you.
*
Pregnant (if female)
Suffering from severe injuries (Eg. Road traffic accident, Polytrauma, Head injury etc.)
Suffering from an acute injury needing immediate medical attention
Experiencing acute abdomen or chest pain
None of the above
What is the location of your pain? (select all that apply to you)
*
Neck
Shoulder
Back
Knee
Ankle/Foot
Hips
Other
What is the intensity of your pain at this moment?
*
No Pain
1
2
3
4
5
6
7
8
9
Worst Imaginable Pain
10
1 is No Pain, 10 is Worst Imaginable Pain
When is a good time to call you?
*
Anytime
Morning (8 AM-12 Noon)
Afternoon (12 - 4 PM)
Evening ( 4- 8 PM)
Are you open to getting an expert second opinion via paid consultation with our Pain Specialist doctor?
*
Yes
No
Not Sure
Is there anything else you wish to share with us not covered in this form?
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Submit
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